by Bart Jansen, USA TODAY

by Bart Jansen, USA TODAY

WASHINGTON - The ferry Seastreak Wall Street crashed into a New York pier in 2013 and injured scores of passengers because the captain became confused by the ship's poorly designed controls, crash investigators ruled unanimously Tuesday.

The experienced captain had put the ship under manual control on the trip from Atlantic Highlands, N.J., near the Verrazano Bridge because he thought the propellers were fouled, according to National Transportation Safety Board investigators.

But the 131-foot-long ship isn't designed to dock in manual mode, as happened in the accident. Instead, it is supposed to be in what is called "combinator" mode, which allows easier manipulation of speed and direction.

Deborah Hersman, the NTSB chairman, said the captain was experienced and conscientious. But she said he made mistakes in a system where vulnerabilities were apparent for years.

"Accidents like a fraying rope are always a series of missed opportunities, but the blame typically falls on the final strand in that rope that breaks," she said.

To prevent future accidents, the NTSB repeated two major recommendations from earlier ferry accidents that have gone without action for years.

One major recommendation is for ferries to have safety-management systems, which help crews prevent accidents with a docking checklist that would have revealed the ship was in the wrong mode for docking. The Coast Guard is working on such a rule.

The other major recommendation is for ferries to have voyage-data recorders like planes, so that investigators can better unravel how an accident happened. But the Coast Guard has ignored such advice for 20 years because of the cost.

The Seastreak, one of seven ferries its namesake company operates, was making its second trip of the morning Jan. 9, 2013, when the collision occurred about 8:41 a.m.

The ship was carrying 326 passengers and five crewmembers. The collision injured 79 passengers - four seriously - and one crewmember.

"We know that some people's lives were changed forever by this accident," said Hersman, who said some passengers were "lucky to be alive."

The captain, who was controlling the vessel at the time, reduced the speed from 30 knots to 12 knots as he prepared to dock at Pier 11 on the East River in Lower Manhattan.

To better see where he was going, the master told investigators that he shifted control from a center console to one on the starboard, or right, side.

But he found the thrust controls didn't work at the side console, so he returned to the center console, which also didn't respond. Then, he said, he quickly returned to the side console as the right side of the ship struck the dock.

NTSB investigators found that the controls appeared to not work as expected because they were in manual mode. Buttons and levers the captain used to guide the ship are all the same size and same size text, which made it difficult for the captain to decipher the problem as the ship approached the dock, according to investigators.

Board member Robert Sumwalt said the board has recommended a safety management system since 2008.

Congress gave the Coast Guard authority in 2010 to require safety management systems, but no rule has been proposed yet. The Coast Guard is working on a proposed regulation, but Sumwalt complained it would take years longer to complete the rule and phase it in.

"Nothing tangible has been done," Sumwalt said. "It is unacceptable."

Seastreak is developing its own safety-management system voluntarily.

The NTSB has also previously recommended recorders on passenger vessels for 20 years. But the Coast Guard rejected that recommendation after a 2008 study found it wouldn't be cost-effective to require the equipment be installed on the ships.